What medications should be avoided or used with caution in a geriatric patient with a complex medical history and potential dementia, according to the Beers criteria (Beers criteria for potentially inappropriate medication use in older adults)?

Beers Criteria Quick Reference Guide

High-Priority Medications to Avoid in Most Older Adults

The American Geriatrics Society identifies central nervous system agents—particularly benzodiazepines, nonbenzodiazepine hypnotics (Z-drugs), and antipsychotics—as the highest-risk medications that must be avoided in older adults due to increased mortality, cognitive impairment, delirium, falls, fractures, and motor vehicle accidents. 1

Central Nervous System Agents (Highest Risk)

Benzodiazepines (all formulations):

• Avoid: Diazepam (long-acting), lorazepam, clonazepam, temazepam 2
• Risks: Sedation, cognitive impairment, falls with injury, motor skill impairment, habituation, withdrawal syndromes, respiratory depression 2, 1
• Critical interaction: Never combine with opioids—causes severe respiratory depression and death 1

Nonbenzodiazepine Hypnotics (Z-drugs):

• Avoid: Zolpidem, zaleplon 2
• Risks: Same cognitive and fall risks as benzodiazepines 1

Antipsychotics:

• Avoid for behavioral management: Haloperidol (long-term), chlorpromazine, quetiapine, risperidone, olanzapine 2, 3
• FDA Black Box Warning: Increased mortality risk in dementia patients 2, 3
• Risks: Stroke, cognitive worsening, falls, movement disorders, delirium 3
• Limited exceptions: Short-term chemotherapy antiemetic, acute delirium in controlled settings, schizophrenia 3

Anticholinergic Medications

Tricyclic Antidepressants:

• Avoid: All TCAs cause anticholinergic effects and orthostatic hypotension 1

First-Generation Antihistamines:

• Avoid: Diphenhydramine, hydroxyzine—cause sedation, confusion, anticholinergic toxicity 2

Pain Medications

NSAIDs:

• Avoid: Ibuprofen, naproxen, indomethacin 2, 1
• Risks: GI bleeding, acute kidney injury, heart failure exacerbation, hypertension worsening 2, 1
• Alternative: Scheduled acetaminophen for moderate musculoskeletal pain 2

Opioids:

• Use with extreme caution: Morphine, oxycodone, codeine 2
• Risks: Sedation, cognitive impairment, falls, constipation, respiratory depression, addiction 2
• Critical interactions: Never combine with benzodiazepines or gabapentinoids except when transitioning from opioids to gabapentinoids 1

Cardiovascular Medications

Antihypertensives causing hypotension:

• Caution: Any class can cause orthostatic hypotension leading to falls and injury 2

Thiazolidinediones:

• Avoid in heart failure: Worsen fluid retention 1

Endocrine Medications

Sulfonylureas:

• Avoid: Glyburide, glipizide—accumulate in chronic kidney disease with severe hypoglycemia risk 2

Insulin:

• Caution: Short-acting and peak insulins accumulate in acute kidney injury and progressive chronic kidney disease 2

Antidepressants (Specific Agents)

Fluoxetine:

• Avoid: Greater risk of agitation and overstimulation in older adults 4

SNRIs (not SSRIs):

• Avoid in fall/fracture history: Added to 2019 criteria specifically for fall risk 1

Preferred SSRIs:

• Use: Citalopram, escitalopram, sertraline—favorable adverse effect profiles 4
• Start low: 50% of standard adult dose 4

Disease-Specific Medications to Avoid

Dementia or Cognitive Impairment

• Avoid: Anticholinergics, benzodiazepines, antipsychotics 1
• Caution: Cholinesterase inhibitors (donepezil, galantamine) lack long-term benefit in advanced dementia; cause nausea, vomiting, diarrhea, nightmares, bradyarrhythmia 2

History of Falls or Fractures

• Avoid: Benzodiazepines, Z-drugs, antipsychotics, opioids, SNRIs (but not SSRIs) 1
• Caution: Gabapentin when combined with other CNS agents increases fall risk 1

Heart Failure

• Avoid: NSAIDs, thiazolidinediones, certain calcium channel blockers 1

Chronic Kidney Disease

• Avoid or dose-adjust: Ciprofloxacin, TMP-SMX, dofetilide, edoxaban 1
• Avoid: Sulfonylureas (accumulation risk) 2
• Dose-adjust: Gabapentin requires renal dose adjustment 1

Critical Drug-Drug Interactions

Never combine:

• Opioids + Benzodiazepines: Severe respiratory depression and death 1
• Opioids + Gabapentinoids: Increased respiratory depression, overdose, death (exception: transitioning from opioids to gabapentinoids) 1
• TMP-SMX + Warfarin: Increased bleeding risk 1

High-risk combinations:

• Three or more CNS agents: Dramatically increases fall risk (includes antidepressants, antipsychotics, benzodiazepines, Z-drugs, antiepileptics, opioids) 1

Medications Requiring Special Caution

Aspirin for primary prevention:

• Caution ≥70 years: Bleeding risk exceeds cardiovascular benefit 1

Rivaroxaban:

• Caution ≥75 years: Higher bleeding risk for VTE or atrial fibrillation treatment 1

Dextromethorphan/Quinidine:

• Use with caution: Limited efficacy, significant drug interactions, increased fall risk 1

Medications to Deprescribe First

Priority order (highest morbidity/mortality risk):

1. Benzodiazepines and Z-drugs 1
2. Antipsychotics (especially in dementia) 1, 3
3. Opioids (especially with benzodiazepines or gabapentinoids) 1
4. NSAIDs 1
5. Anticholinergics 1

Deprescribing strategy:

• Taper technique: Use EMPOWER method for benzodiazepines; consider cognitive behavioral therapy for anxiety/sleep 2
• Safe to discontinue: Antipsychotics when used for behavioral control, especially with perceived lack of benefit 2, 3
• Non-pharmacological first: Redirection and environmental modifications for behavioral symptoms 3

Supplements and Over-the-Counter Medications

Avoid or minimize:

• Multiple vitamin/mineral supplements: Contribute to medication burden, occasionally cause anorexia without substantiated benefit 2
• Herbal supplements: Glucosamine, turmeric, ginkgo, antioxidants—drug interaction concerns, medication burden, expense, poor evidence of benefit 2

Implementation Strategy

Apply systematically at every care transition:

• Screen: Use Beers Criteria and STOPP/START tools during comprehensive medication reviews 1
• Prioritize: Remove medications with highest morbidity/mortality risks first 1
• Review regularly: Identify deprescribing opportunities at each visit 3
• Screen for interactions: Check for concurrent opioid use before initiating gabapentin 1
• Assess kidney function: Many medications require dose adjustment or avoidance in renal impairment 2, 1

Common pitfall to avoid:

• Do not assume all medications within a class are equally inappropriate—the 2019 update distinguishes SNRIs from SSRIs for fall risk, and fluoxetine from other SSRIs for agitation risk 1, 4